Sunday, March 21, 2010

I haven't posted in a week because I've been dealing with a family medical issue, and have been realizing what a tremendous ordeal it is to be on the patient side of things-- or at least the family side of things. And that even when you're a doctor, even when you're part of the system-- it still doesn't necessarily make things much easier.

My dad had a routine medical procedure performed a couple of weeks ago-- the details don't matter-- and was still feeling some pain at the wound site this past Monday, so he went to the doctor, was sent for an ultrasound, and they discovered a small leak in a blood vessel-- an unusual but not unheard-of complication from the procedure. He was sent to a vascular surgeon for a simple injection-- the standard treatment-- and somehow everything went awry.

From what I was able to gather, the surgeon was in a bit of a rush, a packed day of patients, and should have realized that this particular leak-- due to size and placement-- was not a good candidate for the injection, and he should have scheduled a very minor outpatient surgery to deal with the problem. Instead, he decided to go ahead with the injection, and it immediately caused a blood clot, stopping flow to my dad's entire leg and causing him to need to be rushed into emergency surgery to save the limb.

If this wasn't enough-- while in the recovery room from this surgery, after my mom had gone home, thinking everything was okay-- they discovered my dad was rapidly losing blood, and had to go back in and do a second surgery-- the surgeon (same guy who had botched the injection) had ineffectively tied off a vein in the first surgery-- the tie came loose-- and they had to repair that, and in the process replace 4 units of blood he lost.

Fortunately, this surgery seems to have gone well, with no further complications, and as of this morning, he's out of the hospital-- albeit in pain and with restricted activity for the next 6 weeks-- and doing well.

Beyond questioning the actual competence of the doctor-- the botched injection and improperly tied-off vein in the surgery-- what truly disappointed mewas the lack of communication and accountability throughout the process. When my dad was rushed into the second surgery, my mom received a phone call saying he needed another procedure-- was not told the extent of the problem, nor what had happened in the first surgery to make this one necessary-- and was promised she would be called with an update. She wasn't, and was up the entire night assuming the worst. At the same time, throughout the hospital stay, I was unable to get anyone on the phone to tell me anything, despite being a doctor, despite having attendings here call on my behalf, despite trying to explain that I merely wanted the information about what was going on, and wasn't trying to blame the surgeon.

Immediately after the injection, the surgeon's first priority became protecting himself-- from any criticism, from any accountability, from any possibility of blame-- by making it impossible to get any information from him. The morning after the second surgery, after trying unsuccessfully to get him on the phone, I sent him an e-mail-- explaining I was my dad's health care proxy, I wanted to talk to him about what had happened, I was disappointed my family was not kept in the loop overnight to know what was going on and whether my dad was alive or dead, I wanted to know the risks going forward, the treatment plan. 12 hours later I received a response saying he does not communicate with patients via e-mail and that his first priority is patient care and not "coddling the family." Again I tried calling and could not reach him-- it was not until I got the head of the resident program at my hospital to place a call that I was able to get a response, and that response was severely lacking.

The lesson learned-- and I've changed a lot of details here, so I don't want to get into the medicine specifically-- the lesson learned for me as a doctor has been about communication. Problems get worse when families aren't kept in the loop. They don't always know how you best like to communicate, they don't always know the questions to ask, they don't necessarily how to reach you, and it shouldn't be their responsibility, it should be ours. Having seen how anxious my mom became, how out of the loop I felt even as a doctor-- I realize that even on the medicine side (as opposed to surgery), it's on me to reach out, it's on me to share promptly and completely, and not to always put "call patient's family" at the bottom of the list. Better to over-communicate than under-communicate. Better to assure them you're on their side instead of fighting against them and treating them as a nuisance. I will communicate more, after this. I will learn a lesson even if that surgeon won't.

Thursday, March 11, 2010

We had a workshop this afternoon about dealing with alcoholism-- identifying patients who may be alcoholics, guiding them toward treatment, etc. A recovering alcoholic spoke to the group, told us the lies he would tell his doctor, told us some signs to watch out for...

It's interesting to think about where the line is between what a doctor is expected to do and what he isn't, and a lot of it depends on the context. During my inpatient rotations, I've seen a lot of alcoholics come into the hospital, with all sorts of problems-- and never once did I see anyone talk to them about treatment. We treated the immediate medical issue, released the patient, and, as often as not, I'd see the same patient back again, after another drunken fall or other consequence of the alcohol. In the inpatient setting, the focus is on fixing and releasing.

But in the outpatient clinic, we do talk about treatment, we talk about addiction, and therapy, and I've heard people mention AA. The difference, I think, speaks a little bit to why I'm drawn to outpatient care more than inpatient. I don't just want to deal with the acute problems, I want to help the patients have better lives. I want to fix the big picture as much as the small. Not that the things they're coming to the ER with are small. But I don't know how to better articulate the difference.

Monday, March 8, 2010

Okay, let me try and correct some faulty patient assumptions. These are all from one patient-- ONE CRAZY PATIENT-- in clinic today.

1. We don't prescribe medication based on body weight. I can see you're a small woman. That doesn't mean you should be cutting your antibiotics in half. I'm giving you the right dosage. You don't have to keep questioning it.

2. You're not allergic to water. You need to keep yourself hydrated. It's important. I don't know who told you you're allergic to water. It wasn't a doctor. You're not. Your body is mostly water. Drink more water.

3. Even though your blood work came back fine three years ago, I still have to do it again. Things change. That's the whole point. You didn't have these symptoms three years ago. You do now. So I have to check. A blood test isn't like an IQ test. I'm not just testing for blood type. It's important.

4. Just because you and your husband sleep in the same bed doesn't mean you should take his medication. In fact, sleeping in the same bed has nothing to do with sharing his medication. "But I already have all of his germs" is not a sensible reason to take his medication. At all.

5. Your bowel movements don't change your weight by ten pounds. You aren't ten pounds heavier than last visit because you haven't gone to the bathroom in two days. Sorry. Not correct.

6. You can eat all the vegetables you want. The pesticides will not hurt you. And even if they will, they won't hurt you more than your diet of red meat and ice cream does.

7. Headaches are not caused by the sun.

8. Your blood pressure has nothing to do with which bra you happen to be wearing. "My blood pressure is always higher when I wear this bra" is not a comment grounded in any sort of logic at all, and when you tell me this, I have no idea how to respond without laughing at you.

9. Just because I don't have a vagina doesn't mean I can't tell you what's "normal down there." The symptom you are complaining about is not normal. It's not "normal for you" or "not a problem" just because you think it is. And even though I don't have one myself, I am a doctor, and so I know things.

10. Just because the "dye" they use in an angiogram is pronounced the same way as the word "die" does not mean it is going to kill you. They don't call it "dye" because you're going to "die" from it. They call it dye because it is dye. I don't know why you don't understand this, especially since your first name is also a word, and it doesn't mean you are what that word is. Good grief.

Thursday, March 4, 2010

A patient in clinic this afternoon didn't like me. I don't know, sometimes you don't click. He was this big guy, mid-50s, seemed to want a doctor who looked older, more imposing. He made a few jokes about how young I am, and then got annoyed when I asked about his eating habits (he's overweight, elevated blood pressure, history of high cholesterol). One of my supervising doctors popped in to grab a file, and the patient starts making a fuss to her. "I want a new doctor. This guy is incompetent." My supervisor brushed him off, and that just made him more annoyed. He walked into the hallway and started yelling after her-- "He's not qualified to be a doctor. He shouldn't be a doctor. He should be a train conductor."

And of course I didn't really know what to do-- I didn't want to argue with him, but I felt like I should try to reason with him and get him out of the hallway. But, gosh-- train conductor? So specific, and a little baffling. He didn't say I should be a high school student, or, I don't know, a waiter, or something else relatively menial. A train conductor. Why did he think I should be a train conductor? I'd be a terrible train conductor. I was running 25 minutes late-- and I didn't even really know the way to the examining room I was supposed to use. Those are both terrible characteristics for a train conductor. I don't know why I've been overthinking this-- it just seemed so oddly specific. Then again, my patient was probably crazy, so I really shouldn't be considering his career advice as if he has any idea what he was talking about.

Tuesday, March 2, 2010

Two extremes on the patient spectrum. The ones who want control over their medical care, and the ones who don't. We talk a lot about making sure patients give informed consent, that we don't just bully them into signing off on risky procedures or letting us do anything they don't understand. But we don't talk about the flip side-- and it's just as important-- patients who assume we're going to do what we need to do, and that if we're asking them whether they want something, it must mean they actually have a choice, and it's okay for them to say no. I feel like we're trained to soften things-- "we need to go in and do so-and-so procedure, it will really help you, here are the risks...." But you soften it too much, and a scared patient can be like, "that sounds risky, I don't want that." And then what? Do they realize they're refusing treatment they need to save their life, or do they think they're just making the safer choice between doing something scary and not doing anything at all?

I covered someone's shift on the floors today and had to deal with a patient who needs a cardiac procedure, the cardiology fellow went in, explained it, and the patient-- scared and not very knowledgeable-- said no. And so the fellow left the room, didn't move forward with it for now-- but did the patient really know what she was doing? I went back in, asked the patient if there's anyone she can call, she called her husband, and he basically yelled at her through the phone and said she has to have this thing, and she had me get the fellow back, and she gave her consent. Some would say she was bullied into it-- although if her family bullies her into it, at least we're not the ones who get sued-- but in this case, hey, she needs it, her husband got through to her in a way the doctors couldn't. Is that a bad thing? Unless this woman wants to die-- and she didn't, she was just scared-- she needed the procedure. And didn't understand the choice she was making, because we soft-pedaled how urgent this was, all to pretend she has a choice and needed to give consent. But consent means nothing to a confused and scared patient who thinks we're saying there's an option not to have an invasive procedure.

Yet if I were to argue we need a broader view of consent-- asking something like, "do you want us to do everything we need to do, in our best medical judgment, to save your life?" and not asking about every pill and every treatment option-- I'd be shot down instantly-- that's not really consent, patients have a choice.... We're doctors, they assume we know things, they assume if we need to do something to help them, we're going to do it, whether they "consent" or not. At least some patients. Problem is knowing which ones.